Receiving an annual flu vaccination may be linked to a reduction in risk of ischaemic stroke, according to a study which appears online in the journal Neurology.
“Studies have shown that getting the flu increases your risk of having a stroke, but research is still being collected on whether getting the flu vaccine can help protect against a stroke,” said study author Francisco J. de Abajo, MD, MPH, PhD, of the University of Alcalá in Madrid. “This observational study suggests that those who have a flu shot have a lower risk of stroke. To determine whether this is due to a protective effect of the vaccine itself or to other factors, more research is needed.”
In their study, the researchers accessed a health care database in Spain, identifying 14 322 participants aged 40 years and over with a first stroke over a 14-year period. Each person who had a stroke was matched to five people of the same age and sex who did not have a stroke.
Then the researchers looked at whether people had received the influenza vaccine at least 14 days before the stroke or before that same date for those who did not have a stroke.
A total of 41.4% of those who had a stroke had received the flu vaccine, compared to 40.5% of those who did not have a stroke – seemingly indicating that the flu jab added to risk. But those vaccinated were more likely to be older and to have other stroke risk factors such as hypertension and high cholesterol. Once these were adjusted for, the researchers found that those who received a flu shot had a 12% reduced stroke risk.
The pneumonia vaccine was also investigated for any effect on the risk of stroke, but none was found.
“These results are yet another reason for people to get their yearly flu shot, especially if they are at an increased risk of stroke,” de Abajo said. “To be able to reduce your risk of stroke by taking such a simple action is very compelling.”
Since the study was observational, it only shows an association and cannot prove a causal link. Other unmeasured factors could also mediate stroke risk,
New research published in the Journal of Bone and Mineral Research identified a number of risk factors for cardiovascular disease in adults with compromised bone health, such as osteoporosis or a fragility fracture. Male sex was associated with a 61% increase in cardiovascular risk in the case of osteoporosis.
The prospective cohort study used data from a UK primary care database. Major adverse cardiovascular events (MACE, a composite outcome for the occurrence of either myocardial infarction [MI], stroke, or CVD death) were identified in patients aged 50 years or older at high or imminent fracture risk identified in three different cohorts (not mutually exclusive): recently diagnosed with osteoporosis (OST, n = 65 295), incident fragility fracture (IFX, n = 67 065), and starting oral bisphosphonates (OBP, n = 145 959). About 1.90%, 4.39%, and 2.38% of the participants in OST, IFX, and OBP cohorts, respectively, experienced MACE events. IFX was the cohort with the higher risk: MACE incidence rates (cases/1000 person-years) were 19.63 (18.54–20.73) in OST, 52.64 (50.7–54.5) in IFX, and 26.26 (25.41–27.12) in OBP cohorts.
The researchers found that risk factors for MACE in the three cohorts included male sex, older age, smoking, alcohol consumption, atrial fibrillation, use of anti-hypertensive medications, history of heart attack or stroke, established cardiovascular disease, low kidney function, high systolic blood pressure, elevated cholesterol level, and use of multiple concomitant medicines.
“Although there are some calculators to produce risk estimates of cardiovascular disease, these are not targeted at those at high risk of fracture,” said corresponding author Daniel Prieto-Alhambra, MD, PhD, of the University of Oxford. “To our knowledge, this is the first study to identify cardiovascular disease risk factors for osteoporotic individuals using data that is routinely collected and readily available.”
Women and men share most of the same risk factors for cardiovascular disease (CVD), according to a study published in The Lancet. This is the first such study to include people not only from high income countries, but also from low- and middle-income countries – which have the highest burden of CVD. One of the differences observed was a greater sensitivity to diet in women than in men.
The global study assessed risk factors, including metabolic (eg hypertension, obesity and diabetes), behavioural (smoking and diet), and psychosocial (economic status and depression) in about 156 000 people without a history of CVD between the ages of 35 and 70. Living in 21 low, middle and high-income countries on five continents, they were followed for an average of 10 years.
“Women and men have similar CVD risk factors, which emphasises the importance of a similar strategy for the prevention of CVD in men and women,” said first author Marjan Walli-Attaei, a research fellow at the Population Health Research Institute (PHRI) of McMaster University and Hamilton Health Sciences (HHS).
Overall, women had a lower risk of developing CVD than men, especially at younger ages.
However, diet was more strongly associated with CVD risk in women than men – “something that’s not been previous described, and which requires independent confirmation,” said Salim Yusuf, lead investigator of the study, senior author, executive director of PHRI, professor of medicine at McMaster University, and cardiologist at HHS.
High levels of bad (LDL) cholesterol and symptoms of depression were more strongly associated with CVD risk in men than in women. The patterns of these findings were generally similar in high-income countries and upper-middle-income countries, and in low-income and lower-middle-income countries.
Blood type may be associated with early-onset stroke risk, according to a new meta-analysis, which was published in the journal Neurology. The meta-analysis included all available data from genetic studies focusing on ischaemic strokes in adults under age 60.
“The number of people with early strokes is rising. These people are more likely to die from the life-threatening event, and survivors potentially face decades with disability. Despite this, there is little research on the causes of early strokes,” said study co-principal investigator Steven J. Kittner, MD, MPH, Professor of Neurology at University of Maryland School of Medicine (UMSOM).
He and his colleagues performed a meta-analysis of 48 studies on genetics and ischaemic stroke that included 17 000 stroke patients and nearly 600 000 healthy controls. They looked for genetic variants associated with a stroke and found a link between early-onset stroke (before age 60) and the area of the chromosome that includes the gene that determines whether a blood type is A, AB, B, or O.
The study found that people with early stroke were more likely to have blood type A and less likely to have blood type O, compared to people with late stroke and people who never had a stroke. Both early and late stroke were also more likely to have blood type B compared to controls. After adjusting for sex and other factors, researchers found that, compared to those with other blood types, blood type A had a 16% higher risk while blood type O had a 12% lower risk.
“Our meta-analysis looked at people’s genetic profiles and found associations between blood type and risk of early-onset stroke. The association of blood type with later-onset stroke was much weaker than what we found with early stroke,” said study co-principal investigator Braxton D. Mitchell, PhD, MPH, Professor of Medicine at UMSOM.
The researchers emphasised that the increased risk was very modest and that those with type A blood should not worry about having an early-onset stroke or engage in extra screening or medical testing based on this finding.
“We still don’t know why blood type A would confer a higher risk, but it likely has something to do with blood-clotting factors like platelets and cells that line the blood vessels as well as other circulating proteins, all of which play a role in the development of blood clots,” said Dr Kittner. Previous studies suggest that those with an A blood type have a slightly higher risk of developing blood clots in the legs known as deep vein thrombosis. “We clearly need more follow-up studies to clarify the mechanisms of increased stroke risk,” he added.
A limitation of the study was the relative lack of diversity among participants, with only 35% of the participants having non-European ancestry.
All over the world, women with cardiovascular disease (CVD) generally experience worse outcomes and are less likely to attend prevention and rehabilitation programmes than men. An expert panel has developed a clinical practice guideline endorsed by 24 clinical societies worldwide to provide guidance to the cardiac rehabilitation community on how to deliver more effective women-focused programming. The guideline appears in the Canadian Journal of Cardiology.
“It has long been established that women are significantly less likely to access and complete cardiac rehab (CR), and that their outcomes are often poorer, despite greater need than men,” explained lead author Sherry L. Grace, PhD, a professor at the University of Toronto. “Accordingly, ‘women-focused’ models of CR have been developed to better engage women and optimise their outcomes. There is now sufficient evidence on women-focused CR to make recommendations to the CR community.”
The clinical practice guideline provided by the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) offers guidance to the CR community on how best to design programs for women with CVD, including stroke and peripheral arterial disease (PAD), and how to increase their engagement, with the goal of optimising women’s health outcomes. Cost, resource implications, feasibility, and patient preferences are foremost considerations in the recommendations.
The ICCPR identified women-focused CR researchers through a review of the scientific literature and programs offering women-focused CR around the world as identified through ICCPR’s Global Audit. Individuals and programs that consented to participate formed a writing and consensus panel including experts with diverse geographic representation who are multidisciplinary healthcare providers, a policymaker, and patient partners. This group drafted and reviewed the recommendations. The draft then underwent external review from CR societies internationally and was posted online for public comment before finalisation. One third of the studies identified in the review that formed the basis for the guideline came from Canada, which is considered to be a leader in women-focused CR.
The guideline presents 15 recommendations relating to referral (ie, automatic plus encouragement), setting (eg, choice of delivery mode, environment, tailoring, and staff training), and delivery (eg, session timing options, preferred form of exercise, psychosocial assessment and care, and education on women and heart disease). When adopted, these recommendations and the associated tools compiled can feasibly support some degree of women-focused CR as part of any program.
Key recommendations are:
Women should be systematically referred to CR to reduce bias and encouraged to attend before hospital discharge through two-way fulsome discussion to overcome gender-related barriers.
Particular considerations when developing a woman’s tailored rehab plan include considering their contextual and full clinical history, such as any mental health and psychosocial issues, menopausal status, frailty, cancer history, and concerns about urinary incontinence, falls risk/osteoporosis, as well as autoimmune conditions.
All programmes should offer women-focused programming, comprising as many of the definitional elements of women-focused CR as possible. Where resources are limited, this could include offering, for example, some women-only virtual education or exercise sessions or peer support programs.
Women should be given a choice in participating in a centre-based (clinical or community) or home-based setting, delivered in a women-friendly environment, and their needs/preferences should be taken into consideration when formulating their programs.
Programs should include a strong psychosocial component, choice of exercise modalities, as well as specific education on women and CVD. The psychosocial needs of women should be assessed and addressed in an evidence-based manner (eg, social support, relationship health, depression, anxiety, stress, socioeconomic issues, informal caregiving activities).
“For the first time, there are a consensus definition and recommendations for women-focused CR, so it is hoped now that many programmes will incorporate these elements into their programmes,” said Prof Grace. “If implemented, more women may engage in CR, and as a result have significantly greater quality and quantity of life.”
In the Journal of Applied Physics, researchers developed a method to identify aortic valve stenosis using complex network analysis that is accurate, simple to use, and low-cost.
Aortic valve stenosis occurs when the aortic valve narrows, constricting blood flow from the heart through the artery and to the entire body. In severe cases, it can lead to heart failure. Identifying the condition can be difficult in remote areas because it requires sophisticated technology, and diagnoses at early stages are challenging to obtain.
“Many rural health centres don’t have the necessary technology for analysing diseases like this,” said author M.S. Swapna, of the University of Nova Gorica and the University of Kerala. “For our technique, we just need a stethoscope and a computer.”
The diagnostic tool works based on the sounds produced by the heart. The organ creates a “lub” noise as it closes the mitral and tricuspid valves, pauses as ventricular relaxation occurs and the blood fills in, then makes a second noise, “dub,” as the aortic and pulmonary valves close.
Swapna and her team used heart sound data, collected over 10 minutes, to form a graph. This was then split into sections, with each part representing with a node on the graph. If the sound in that portion of the data was similar to another section, a line was drawn between the two nodes.
In a healthy heart, the graph showed two distinct clusters of points, with many nodes unconnected. In contrast, a heart with aortic stenosis contained many more correlations and edges.
“In the case of aortic stenosis, there is no separation between the ‘lub’ and ‘dub’ sound signals,” explained Swapna.
The researchers used machine learning to examine the graphs and identify those with and without disease, achieving a classification accuracy of 100%. Their method takes the correlation of each point under consideration, making it more accurate than others that only consider the strength of the signal, and it does so in less than 10 minutes. As such, it could be useful for early-stage diagnoses.
So far, the method has only been tested with data, not in a clinical setting. The authors are developing a mobile application that could be accessed worldwide. Their technique could also be used to diagnose other conditions.
“The proposed method can be extended to any type of heart sound signals, lung sound signals, or cough sound signals,” said Swapna.
A new epidemiological study published in The Lancet shows that patients with autoimmune disease have a substantially higher risk (between 1.4 and 3.6 times depending on which autoimmune condition) of developing cardiovascular disease (CVD) than people without an autoimmune disorder. This excess risk is comparable to that of type 2 diabetes, a well-known risk factor for cardiovascular disease.
Although earlier research has suggested associations between various different autoimmune disorders and a higher risk of cardiovascular disease, these studies were often too small and limited to selected autoimmune or selected cardiovascular conditions to draw conclusive evidence on the necessity of CVD prevention among patients with autoimmune disease.
At the annual congress of the European Society of Cardiology, researchers presented the outcome of a thorough epidemiological investigation into possible links between 19 of the most common autoimmune disorders and CVD. The research shows for the first time that cardiovascular risks affect autoimmune disease as a group of disorders, rather than selected disorders individually.
The whole cardiovascular disease spectrum
In the study, the authors show that the group of 19 autoimmune disorders they have studied accounts for about 6% of cardiovascular events. Importantly, excess cardiovascular risk was visible across the whole cardiovascular disease spectrum, beyond classical coronary heart disease, including infection-related heart disorders, heart inflammation, as well as thromboembolic and degenerative heart disorders, suggesting the implications of autoimmunity on cardiovascular health are likely to be much broader than originally thought. Furthermore, the excess risk was not explained by traditional cardiovascular risk factors such as age, sex or smoking. Another noteworthy finding: the excess risk is particularly high among patients with autoimmune disorders under 55 years and suggests that autoimmune disease is particularly important in causing premature cardiovascular disease, with the potential to result in a disproportionate loss of life years and disability.
The study was based on UK electronic health with data from about one-fifth of the current UK population. The researchers assembled a cohort of patients newly diagnosed with any of the nineteen autoimmune disorders. They then looked at the incidence of twelve cardiovascular outcomes – an unprecedented granularity that was made possible by the very large size of the dataset – in the following years, and they compared it to a matched control group. The risk of developing CVD for patients with one or more autoimmune disorders was on average 1.56 times higher than in those without autoimmune disease. The excess risk also rose with the number of different autoimmune disorders in individual patients. Among the disorders with the highest excess risk were systemic sclerosis, Addison’s disease, lupus and type I diabetes.
Need for targeted prevention measures
The results show that action is needed, said Nathalie Conrad, lead author of the study. “We see that the excess risk is comparable to that of type 2 diabetes. But although we have specific measures targeted at diabetes patients to lower their risk of developing cardiovascular disease (in terms of prevention and follow-up), we don’t have any similar measures for patients with autoimmune disorders.” Conrad also noted that the European Society of Cardiology guidelines on the prevention of cardiovascular diseases, do not yet mention autoimmunity as a cardiovascular risk factor, only mentioning specific disorders such as lupus, nor do they list any specific prevention measures for patients with autoimmune disease.
Conrad hopes the study will raise awareness among patients with autoimmune disease and clinicians involved in the care of these patients, which will include many different specialties such as cardiologists, rheumatologists, or general practitioners. ‘We need to develop targeted prevention measures for these patients. And we need to do further research that helps us understand why patients with an autoimmune disorder develop more cardiovascular diseases than others, and how we can prevent this from happening.’
The underlying mechanisms are still poorly understood. Conrad said: “The general hypothesis is that chronic and systemic inflammation, which is a common denominator in autoimmune disorders, can trigger all sorts of cardiovascular disease. Effects of autoimmune disease on connective tissues, small vessels, and cardiomyocytes, and possibly some of the treatments commonly used to treat autoimmunity are also likely to contribute to patients’ cardiovascular risk. This really needs to be investigated thoroughly.”
An expert consensus decision pathway on the role of nonstatin therapies for LDL-C lowering in the management of atherosclerotic cardiovascular disease (ASCVD) risk reduction has been published to address the recent development and commercial availability of newer nonstatin agents. The American College of Cardiology drafted the decision pathway in order to bridge gaps in expert guidance on the topic.
The 2022 ACC Expert Consensus Decision Pathway on the Role of Nonstatin Therapies for LDL-Cholesterol Lowering in the Management of Atherosclerotic Cardiovascular Diseases Risk is available online in the Journal of the American College of Cardiology. It was endorsed by the National Lipid Association.
The document provides guidance on clinical scenarios not covered in the 2018 AHA/ACC Guideline on the Management of Blood Cholesterol and refines criteria for treating individuals determined by baseline LDL-C levels. The clinical policy focuses on individuals at very high-risk as well as not very high-risk of future ASCVD events, individuals currently with or without a clinical diagnosis of familial hypercholesterolemia, primary prevention for individuals with and without diabetes, and individuals with statin-associated side effects. The writing committee also addresses factors to consider in the clinician-patient discussion reinforcing patient preference with regard to the addition of nonstatin therapies.
A three-drug medication ‘polypill’ containing aspirin, ramipril, and atorvastatin is effective in preventing secondary adverse cardiovascular events in people who have previously had a heart attack, reducing cardiovascular mortality by 33% in this patient population.
“The results of the SECURE study show that for the first time that the polypill, which contains aspirin, ramipril, and atorvastatin, achieves clinically relevant reductions in the recurrent cardiovascular events among people who have recovered from a previous heart attack because of better adherence to this simplified approach with a simple polypill, rather than taking them separately as conventional,” said Valentin Fuster, MD, PhD, who led the trial.
Standard therapy for patients recovering from myocardial infarction includes three different drugs: an antiplatelet agent (like aspirin); ramipril or a similar drug to control blood pressure; and a lipid-reducing drug, such as a statin. However, adherence is poor over 50% of patients not taking their medications.
“Although most patients initially adhere to treatment after an acute event such as an infarction, adherence drops off after the first few months. Our goal was to have an impact right from the start, and most of the patients in the study began taking a simple polypill in the first week after having a heart attack,” Dr Fuster explained.
“Adherence to treatment after an acute myocardial infarction is essential for effective secondary prevention,” said José María Castellano, MD, study first author.
Scientists at the Spanish National Center for Cardiovascular Research (CNIC) and Ferrer developed the polypill. It was first shown that prescription of their polypill significantly improved treatment adherence among patients recovering after a myocardial infarction, in the FOCUS study.
The CNIC team launched the SECURE study, an international randomised clinical trial, to determine whether the improved treatment adherence with the polypill translated into a reduction in cardiovascular events. The polypill analysed in the study, marketed as Trinomia, contains aspirin (100mg), the angiotensin-converting enzyme inhibitor ramipril (2.5, 5, or 10mg), and atorvastatin (20 or 40mg).
“The polypill, being a very simple strategy that combines three essential treatments for this type of patient, has proved its worth because the improved adherence means that these patients are receiving better treatment and therefore have a lower risk of recurrent cardiovascular events,” added Dr Castellano.
SECURE included 2499 patients from seven European countries recovering after a heart attack. Study participants (average age 76 years, 31% female) were randomised to receive standard therapy or the CNIC polypill. The study population included 77.9% with hypertension, 57.4% with diabetes, and 51.3% with a smoking history.
Researchers analysed the incidence of four major cardiovascular events: death from cardiovascular causes, non-fatal myocardial infarction, non-fatal stroke, and need for emergency coronary revascularisation. The study followed patients for an average of three years and produced conclusive results: patients taking the CNIC polypills had a 24% lower risk of these four events than patients taking the three separate drugs.
The standout finding of the study is the effect of the polypill on the key outcome of cardiovascular-related death, which showed a relative reduction of 33%, from 71 patients in the group receiving standard treatment to just 48 in the polypill group. Importantly, the study found that patients in the polypill group had a higher level of treatment adherence than those in the control group, in line with the earlier FOCUS study, and in part such good adherence appears to explain the benefits of the simple polypill.
“The 33% reduction in cardiovascular mortality demonstrates the efficacy of treatment with Trinomia compared to standard treatment. These results ratify our purpose of making a positive impact in society and represent an important step in our mission to provide significant and differential value to people who suffer from serious health conditions,” explains Oscar Pérez, Chief Marketing, Market Access and Business Development Officer at Ferrer.
“The SECURE study findings suggest that the polypill could become an integral element of strategies to prevent recurrent cardiovascular events in patients who have had a heart attack. By simplifying treatment and improving adherence, this approach has the potential to reduce the risk of recurrent cardiovascular disease and death on a global scale,” added Dr Fuster.
A new Australian and New Zealand Journal of Public Health study has found that Australian children who were born via caesarean section (C-section) have a greater risk of cardiovascular disease (CVD) and obesity. These findings have prompted a call to limit the increasingly popular practice.
According to a Lancet review, C-sections are already known to have a number of negative outcomes, with evidence higher rates of maternal mortality and morbidity than after vaginal birth. C-sections are further associated with an increased risk of uterine rupture, abnormal placentation, ectopic pregnancy, stillbirth, and preterm birth. Short-term risks of C-section include altered immune development, an increased likelihood of allergy, atopy, and asthma, and reduced gut microbiome diversity. Associations of C-section with greater incidence of late childhood obesity and asthma are frequently reported.
Researchers used data from the Longitudinal Study of Australian Children to analyse the health outcomes of children delivered by C-section.
“C-section births have risen across the world with a disproportionately higher rate in developed countries. In Australia, the C-section birth rate has increased from 18.5% in 1990 to 36% in 2019 and nearly half of Australian babies are projected to be caesarean born by 2045,” said study author Dr Tahmina Begum.
A relationship was discovered between C-section births and certain cardiovascular disease (CVD) risk factors in children.
“Four out of six individual CVD risk components and the composite index of the five CVD risk components showed a positive association with C-section birth. Our study also provided a direct relationship between C-section and increased overweight and obesity among children at 10–12 years of age,” said Dr Fatima.
A biologically plausible link involved the gut microbiome, she said. “There’s an altered microbial load from C-section birth as compared to vaginal birth. This altered microbial ecosystem hampers the ‘gut-brain axis’ and releases some pathogenic toxins that cause metabolic damage.”
Other possible causes included foetal stress from physiological or pharmacological induction of labour during a C-section. She said the study provides important insights into health care policy and the strategic direction towards chronic disease risk reduction.
“Growing rates of C-sections conducted for non-clinical reasons is a major public health concern that calls for a reduction in the rate of unnecessary C-sections and their associated human and economic costs,” said Dr Begum.
